Obsessive compulsive disorder (OCD) is a condition that has recently been given a significant amount of TV airplay and media coverage, perhaps most notably in the Channel 4 documentary Jon Richardson: A little bit OCD, which received mostly good reviews from mental health groups.

Despite this reasonable public profile, our knowledge about the best way to care for people with OCD remains relatively poor. There isn’t much high quality research being published in the field and, as a result, guidance for professionals is thin on the ground. NICE have published a guideline on OCD and BDD (body dysmorphic disorder), but this came out in 2005 and has not been updated since. It’s time for an update and that’s what we have this week with a new 24 page publication from NICE, which brings together the best available evidence that’s been published in the last decade.

Methods

Comedian Jon Richardson helped improve public understanding of OCD through his TV documentary

The ‘evidence update’ has been carried out by a group of topic experts including psychiatrists, psychotherapists, GPs, researchers and information scientists.

They searched a wide range of databases looking for systematic reviews and RCTs on OCD and BDD and limited their results to publications from 30 Oct 2003 (the end of the search period of NICE clinical guideline 31) to 2 April 2013.

They found 1,247 unique references from this literature search and whittled that long-list down to 16 papers to include in their final report (4 reviews and 12 trials), all of which are included in the links section at the end of this blog.

Key points

Initial treatment options – adults

Telemental health and technology interventions for OCD such as computerised cognitive behavioural therapy (CBT) or telephone CBT may have promise but current evidence is limited.

Acceptance and commitment therapy may improve symptoms of OCD to a greater extent than progressive relaxation training.

Sertraline or group CBT may result in similar response rates, but more people may have clinical remission with group CBT than with sertraline.

Initial treatment options – children and young people

Family-based CBT may be associated with higher rates of response to treatment than psychoeducation plus relaxation training.

Family-based CBT may be associated with long-term benefits, for example no longer meeting the criteria for diagnosis of OCD.

Choice of drug treatment in adults

Paroxetine may be effective in people whose OCD symptoms do not respond to venlafaxine. Venlafaxine may not be as effective in people whose symptoms have not responded to paroxetine. (Note: Venlafaxine is not recommended by current guidance and at the time of publication of this Evidence Update did not have UK marketing authorisation for this indication.)

Many of the drugs listed in this report are not currently approved for use in UK patients with OCD

Continuing treatment with SSRIs after initial response may be associated with lower rates of relapse than placebo.

Poor response to initial treatment in adults

Evidence for antipsychotics added to SSRIs for people whose OCD symptoms have not responded to antidepressants alone is inconclusive. Risperidone and aripiprazole seem to have an effect on symptoms of OCD when added to antidepressants, but quetiapine and olanzapine may have no add-on effects. However, antipsychotics may be associated with increased rates of adverse events. (At the time of publication of this Evidence Update, aripiprazole, olanzapine, quetiapine and risperidone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.)

Acetylcysteine plus SSRIs may result in improvement of symptoms of OCD compared with SSRIs plus placebo. (Acetylcysteine is not recommended by current guidance and at the time of publication of this Evidence Update did not have UK marketing authorisation for this indication.)

The anticonvulsant drugs lamotrigine and topiramate may result in improved OCD symptoms as add-on therapy to SSRIs compared with SSRIs plus placebo, but further research is needed. Topiramate may be associated with increased adverse events. (Lamotrigine and topiramate are not recommended by current guidance and at the time of publication of this Evidence Update did not have UK marketing authorisation for this indication.)

Poor response to initial treatment in children and young people

CBT plus drug treatment with SSRIs may result in better outcomes on persistent symptoms of OCD in children than either drug treatment plus low-intensity CBT, or drug treatment alone.

Transcranial magnetic stimulation

Transcranial magnetic stimulation may not be an effective treatment for people with OCD.

None of the new research found changes the core recommendations from the 2005 NICE guidance.

Uncertainties

The update has identified one treatment uncertainty that has been captured in the DUETs database:

André started the Mental Elf website in May 2011.
He has worked as an Information Scientist in Mental Health since the late nineties; initially at Oxford University's Centre for Evidence-Based Mental Health and since 2002 as the Managing Director of Minervation Ltd.
He loves blogging, social media and elves! He also has established interests in evidence-based healthcare, usability testing and web design.